THE GLENDON ASSOCIATION

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Lisa Firestone, Ph.D. Director of Research and Education The Glendon Association Senior Editor PsychAlive.org THE GLENDON ASSOCIATION (For Professionals) www.glendon.org (For the Public) www.psychalive.org

Part One: Facts About Depression

FACTS ABOUT DEPRESSION An estimated 1 in 10 U.S. adults report depression.(cdc) Major depression affects approximately 15 million American adults or about 8 percent of the U.S. population age 18 and older in a given year. (PBS) The prevalence of depression for women is roughly twice that for men. (PBS) Depression affects about 121 million people worldwide. (WHO) Depression is the leading cause of disability and the fourth leading contributor to the global burden of disease worldwide. (WHO) Sources: CDC- http://www.cdc.gov/features/dsdepression/ WHO - http://www.who.int/mental_health/management/depression/definition/en/ PBS - http://www.pbs.org/wgbh/takeonestep/depression/pdf/dep_stats.pdf

FACTS ABOUT DEPRESSION Persons 45-64 years of age have been found to be more likely to meet criteria for major depression. (CDC) By age 18, nearly 25 percent of all youth in the U.S. will have experienced a depressive disorder (Melissa Institute) By the year 2020, depression will be the 2nd most common health problem in the world. (PBS). Depression is one of the most treatable illnesses: 80-90% find relief. (PBS) Sources: CDC- http://www.cdc.gov/features/dsdepression/ PBS - http://www.pbs.org/wgbh/takeonestep/depression/pdf/dep_stats.pdf Melissa Institute - http://www.melissainstitute.org/melissainstitute/documents/conf2010_adolescent_depression.p df

The madness of depression is the antithesis of violence. It is a storm indeed, but a storm of murk. Soon evident are the slowed-down responses, near paralysis, psychic energy throttled back close to zero. Ultimately, the body is affected and feels sapped, drained. - William Styron, Writer

FACTS ABOUT DEPRESSION TREATMENT It is critical for people who are suffering from depression to seek care from a licensed mental health professional who has training and experience in helping people recover from depression. Several approaches to psychotherapy, including cognitive-behavioral, interpersonal, and psychodynamic, help depressed people recover. Psychotherapy offers people the opportunity to identify the factors that contribute to their depression and to deal effectively with the psychological, behavioral, interpersonal, and situational causes. (APA) Medications can be very helpful for reducing the symptoms of depression in some people, particularly in cases of moderate to severe depression. Often a combination of psychotherapy and medications is the best course of treatment. However, given the potential side effects, any use of medication requires close monitoring by the physician who prescribes the drugs. (APA) Sources: APA - http://www.apa.org/topics/depress/recover.aspx# NIMH - http://www.nimh.nih.gov/health/publications/depression/complete-index.shtml

FACTS ABOUT DEPRESSION TREATMENT In a study in which 681 patients with chronic forms of major depression were treated with antidepressants alone or psychotherapy alone, those with a history of early childhood trauma (loss of parents at an early age, physical or sexual abuse, or neglect), responded better to psychotherapy alone than to antidepressant monotherapy. Moreover, the combination of psychotherapy and pharmacotherapy was only marginally superior to psychotherapy alone among the childhood abuse cohort. (Study Published by APA) Of the roughly 15.6 million Americans who have major depression, only 21 percent receive minimally adequate care. (Study Published by APA) Sources: APA - http://www.apa.org/monitor/2010/02/depression.aspx http://www.apa.org/topics/depress/recover.aspx#

SIGNS AND SYMPTOMS Persistent sad, anxious, or "empty" feelings Feelings of hopelessness or pessimism Feelings of guilt, worthlessness, or helplessness Irritability, restlessness OF DEPRESSION Loss of interest in activities or hobbies once pleasurable, including sex Fatigue and decreased energy Difficulty concentrating, remembering details, and making decisions Insomnia, early-morning wakefulness, or excessive sleeping Overeating, or appetite loss Thoughts of suicide, suicide attempts Aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment. Source: NIMH - http://www.nimh.nih.gov/health/publications/depression/completeindex.shtml

POLL #1 Have you or someone close to you experienced depression? - Yes - No

When you're depressed, it's as though this committee has taken over your mind, leaving you one depressing thought after the other. Part of the depression is as though you're punishing yourself for something... Your sense of self, your appreciation for yourself, your respect for yourself, disappears completely. It certainly isn't that your mind goes blank. On the contrary, when you're depressed, your mind beats you to death with thoughts. It never stops. - Rod Steiger, Actor

Definition of the Voice The critical inner voice refers to a well-integrated pattern of destructive thoughts toward our selves and others. The voices that make up this internalized dialogue are at the root of much of our maladaptive behavior. This internal enemy fosters inwardness, distrust, self-criticism, self-denial, addictions and a retreat from goal-directed activities. The critical inner voice effects every aspect of our lives: our self-esteem and confidence, our personal and intimate relationships, and our performance and accomplishments at school and work.

Common Voices in Depression You just don t belong anywhere. You re a horrible person! You don t deserve anything Just look at yourself in the mirror! You re so ugly. No one can stand you! The world is a real mess. Why should you care about anything? Your friends really hate you. Your life is so boring and empty. Don t ever get too happy because the ax is bound to fall. Nobody really likes you. You re an unlovable person.

Common Voices in Depression You deserve all the bad things that are happening to you. Don t you see what effect you have on your family? Can t you see how you make them feel? You re always stirring up trouble, bothering people. Why can t you just stay away? You don't care for anybody. You ve never cared for anybody in your whole life! Don't show anybody how bad you feel. Who do you think you are anyway? You're nothing! Who could love you? You have nothing to offer. You don't deserve anything. Your family would be better off without you. Just stay away, it s the only decent thing to do.

POLL #2 Do you ever experience these types of voices? - Most of them - Some of them - None of them

I could not sleep, although tired. And lay feeling my nerves shaved to pain and the groaning inner voice: oh, you can't teach, can't do anything. Can't write, can't think...i have a good self, that loves skies, hills, ideas, tasty meals, bright colors. My demon would murder this self by demanding that it be a paragon, and saying it should run away if it is anything less. - Sylvia Plath, Poet

Part Two: Where Does the Critical Inner Voice That Causes Depression Come From?

How Voices Pass From Generation to Generation

Attachment Theory Sir John Bowlby, Ph.D. Harry Harlow, Ph.D. Rene Spitz, M.D Mary Ainsworth, Ph.D. Mary Main, Ph.D. Adult Attachment Interview: predicts the baby s attachment to the parent with 80% accuracy before the baby is even born Erik Hesse, Ph.D.

Where do voices come from? Patterns of Attachment in Children Category of Attachment Parental Interactive Pattern Secure Emotionally available, perceptive, responsive Insecure avoidant Emotionally unavailable, imperceptive, unresponsive and rejecting Insecure- anxious/ambivalent Insecure - disorganized Inconsistently available, perceptive and responsive and intrusive Frightening, frightened, disorienting, alarming

Attachment Figures Low Risk Non-Clinical Populations Secure 55-65% Ambivalent 5-15% Avoidant 20-30% Disorganized 20-40% (Given a Best Fit Alternative) High Risk, Parentally maltreated Disorganized 80%

What causes insecure attachment? Unresolved trauma/loss in the life of the parents statistically predict attachment style far more than: Maternal Sensitivity Child Temperament Social Status Culture

Implicit Versus Explicit Memory Implicit Memory Explicit Memory

How does disorganized attachment pass from generation to generation? Implicit memory of terrifying experiences may create: Impulsive behaviors Distorted perceptions Rigid thoughts and impaired decision making patterns Difficulty tolerating a range of emotions

POLL #3 Have you heard of the work of Dan Siegel? - Very familiar - Some experience - Not familiar

The Brain in the Palm of Your Hand Daniel Siegel, M.D. Interpersonal Neurobiology

9 Important Functions of the Pre-Frontal Cortex 1. Body Regulation 2. Attunement 3. Emotional Balance 4. Response Flexibility 5. Empathy 6. Self-Knowing Awareness (Insight) 7. Fear Modulation 8. Intuition 9. Morality

Division of the Mind Parental Ambivalence Parents both love and hate themselves and extend both reactions to their productions, i.e., their children. Parental Nurturance Parental Rejection, Neglect Hostility

Prenatal Influences Disease Trauma Substance Abuse/ Domestic Violence 33

Birth Trauma Baby Genetic Structure Temperament Physicality Sex 34

Self-System Parental Nurturance Unique make-up of the individual (genetic predisposition and temperament); harmonious identification and incorporation of parent s positive attitudes and traits and parents positive behaviors: attunement, affection, control, nurturance; and the effect of other nurturing experience and education on the maturing self-system resulting in a sense of self and a greater degree of differentiation from parents and early caretakers. 35

Personal Attitudes/Goals/Conscience Realistic, Positive Attitudes Towards Self Realistic evaluation of talents, abilities, etc with generally positive/ compassionate attitude towards self and others. Goals Needs, wants, search for meaning in life Moral Principles Behavior Ethical behavior towards self and others Goal Directed Behavior Acting with Integrity

Anti-Self System Unique vulnerability: genetic predisposition and temperament Destructive parental behavior: misattunement, lack of affection, rejection, neglect, hostility, over permissiveness Other Factors: accidents, illnesses, traumatic separation, death anxiety The Fantasy Bond (core defense) is a self-parenting process made up of two elements: the helpless, needy child, and the self-punishing, self-nurturing parent. Either aspect may be extended to relationships. The degree of defense is proportional to the amount of damage sustained while growing up. 37

Voice Process Anti-Self System Self-Punishing Voice Process Behaviors Source 1. Critical thoughts toward self Verbal self-attacks a generally negative attitude toward self and others predisposing alienation Critical parental attitudes, projections, and unreasonable expectations 2. Micro-suicidal injunctions Addictive patterns. Self-punitive thoughts after indulging Identification with parents defenses 3. Suicidal injunctions suicidal ideation Actions that jeopardize, such as carelessness with one s body, physical attacks on the self, and actual suicide Parents covert and overt aggression (identification with the aggressor)

Voice Process 1. Self Soothing Attitudes Anti Self System Self- Soothing Voice Process Behaviors Self-limiting or selfprotective lifestyles, Inwardness Source Parental over protection, imitation of parents defenses 2. Aggrandizing thoughts toward self Verbal build up toward self Parental build up 3. Suspicious paranoid thoughts towards others Alienation from others, destructive behavior towards others Parental attitudes, child abuse, experienced victimization 4. Micro-suicidal Injunctions 5. Overtly Violent thoughts Addictive patterns. Thoughts luring the person into indulging Aggressive actions, actual violence Imitation of parents defenses Parental neglect, parents overt aggression (identification with the aggressor).

Continuum of Self-Destructive Thoughts Negative thoughts exist on a continuum, from mild self-critical thoughts to extreme self-hatred to thoughts about suicide

Continuum of Self-Destructive Thoughts Self-destructive behaviors exist on a continuum from self-denial to substance abuse to actual suicide.

Our Approach to Suicide There is a relationship between these two continuums. How a person is thinking is predictive of how he or she is likely to behave. Thoughts Feelings Event Behavior

Identifying Your Critical Inner Voice 1. Recognize the events that trigger your Critical Inner Voice 2. Recognize the specific outside criticisms that support your Critical Inner Voice 3. Become aware of times you may be projecting your self-attacks onto other people 4. Notice changes in your mood

Part Three: Challenging the Critical Inner Voice

Exercise 1.1: Visualizing the Real You All exercises from Conquer Your Critical Inner Voice My physical abilities: My positive qualities: My interests and activities: My long-term goals: My short-term goals: Where do I stand in relation to my goals?

Exercise 1.2: Your Critical Inner Voice Attacks Self-critical attacks as I statements Self-critical attacks as you statements Example: I don t think I m an attractive person. Example: You re not attractive.

Exercise 1.3: Keeping a Journal: Your Critical Inner Voice/The Real You My critical inner voice as you statements The real me as I statements Example: You re so stupid. Example: Sometimes I struggle with work, but I catch on quickly and then usually do a good job.

PsychAlive Workshop & Journal Journal on PsychAlive at http://www.psychalive.org/category/psychalive-workshop/

Exercise 1.4: A Plan for Action Actions dictated by my critical inner voice Examples: Have another piece of cake. You should just be on your own. You can t trust anyone, so don t get too close. Actions to take that reflect the real me Examples: I want to eat healthy and take care of myself. I don t want to be isolated and will seek out friends I want to stay vulnerable in my close relationships.

Exercise 7.1 Depression and Life Events: Your Critical Inner Voice / The Real You Triggering event Critical inner voices I recall experiencing at the time of the event My realistic thoughts about the event now

Exercise 7.2 Depression: Your Critical Inner Voices and Your Feelings My critical inner voices contributing to depression How these voices left me feeling

Exercise 7.3 You and the Continuum of Self-Destructive Thoughts My critical inner voices Level 1: Thoughts that lead to low self-esteem and self-defeating behaviors Level 2: Thoughts that support the cycle of addiction Level 3: Thoughts that lead to Seriously self-destructive behavior Behaviors I engage in Level 1: Level 2: Level 3:

Exercise 7.4 The Firestone Voice Scale for Self-Denying and Giving-Up Thoughts Circle the frequency with which you experience the following critical inner voices: 0 = Never 1 = Rarely 2 = Once in a While 3 = Frequently 4 = Most of the Time 0 1 2 3 4 You ll save money if you don t take this trip. 0 1 2 3 4 It s too much trouble to go out to dinner. Just stay home. 0 1 2 3 4 You don t deserve happiness. You re such a creep! 0 1 2 3 4 What s so exciting about playing baseball, football, dancing (any activity)? You should just relax and settle down. 0 1 2 3 4 Look at all the work you have to do. You can t afford to take time off. 0 1 2 3 4 You ve always had problems with sex. You should just give it up. 0 1 2 3 4 Why bother trying to get a date? If you don t date, you ll have more time to study. 0 1 2 3 4 Just look at how your friends are acting. They re so immature. They think they re having fun, but they re really just making fools of themselves. Don t be like them! 0 1 2 3 4 You shouldn t be out having fun with all the misery in the world. 0 1 2 3 4 You re too old to have romance in your life. 0 1 2 3 4 What s all this passion in your relationship? You should just settle down. 0 1 2 3 4 Nothing matters anymore. 0 1 2 3 4 Why bother even trying? 0 1 2 3 4 Nothing is any fun anymore. 0 1 2 3 4 Why bother making friends? 0 1 2 3 4 What s the use? What s the point of anything really? 0 1 2 3 4 Your work doesn t matter anymore. Why bother even trying? Nothing matters anyway.

Exercise 7.5 How Your Critical Inner Voice Rationalizes Self-Denial and Giving-Up / What You Realistically Think What my critical inner voice says What I realistically think

Exercise 7.6 The Firestone Voice Scale for Isolation Circle the frequency with which you experience the following critical inner voices: 0 = Never 1 = Rarely 2 = Once in a While 3 = Frequently 4 = Most of the Time 0 1 2 3 4 Wouldn t it be great to go off by yourself and be able to read or watch TV with no one interrupting? 0 1 2 3 4 It s been so tense at work. You need to go off by yourself. 0 1 2 3 4 Why go out with your friends tonight? You could just stay at home and relax. 0 1 2 3 4 You need to get away so you can think about things. 0 1 2 3 4 It s so irritating to have to be around people all day. 0 1 2 3 4 The only way you can relax is to be by yourself. 0 1 2 3 4 You need more space. More time for yourself. 0 1 2 3 4 These aren t your kind of people. Why don t you go off by yourself? 0 1 2 3 4 It s such a hassle to go to that party. You have to get dressed up and put up a front. Why don t you just stay home? 0 1 2 3 4 You re no fun to be around. You should just stay by yourself.

Exercise 7.7 How Your Critical Inner Voice Influences Isolation/ What You Realistically Think What my critical inner voice says What I realistically think

Exercise 7.8 The Firestone Voice Scale for Depression Circle the frequency with which you experience the following critical inner voices: 0 = Never 1 = Rarely 2 = Once in a While 3 = Frequently 4 = Most of the Time 0 1 2 3 4 You just don t belong anywhere. 0 1 2 3 4 You re a horrible person! You don t deserve anything. 0 1 2 3 4 Just look at yourself in the mirror! You re so ugly. No one can stand you! 0 1 2 3 4 The world is a real mess. Why should you care about anything? 0 1 2 3 4 Your friends really hate you. 0 1 2 3 4 Your life is so boring and empty. 0 1 2 3 4 Don t ever get too happy because the ax is bound to fall. 0 1 2 3 4 You should just smash your hand, you creep! You deserve everything that happens to you. 0 1 2 3 4 Nobody really likes you. You re an unlovable person. 0 1 2 3 4 You deserve all the bad things that are happening to you. 0 1 2 3 4 Don t you see what effect you have on your family? Can t you see how you make them feel? 0 1 2 3 4 You re always stirring up trouble, bothering people. Why can t you just stay away? 0 1 2 3 4 You don't care for anybody. You ve never cared for anybody in your whole life! 0 1 2 3 4 Don't show anybody how bad you feel. 0 1 2 3 4 Who do you think you are anyway? You're nothing! 0 1 2 3 4 Who could love you? You have nothing to offer. 0 1 2 3 4 You don't deserve anything. 0 1 2 3 4 Your family would be better off without you. Just stay away, it s the only decent thing to do.

Exercise 7.9 Critical Inner Voices of Depression Your Critical Inner Voice/ The Real You What my critical inner voice says What I realistically think

Exercise 7.10 Plan of Pleasurable Activities Describe the activities I plan to engage in A weekly report of my critical inner voices about my plan

POLL #4 Do you think you could use these exercises to help you feel better? -Yes - Maybe - Seems hard to do

Voice Therapy Cognitive Affective Behavioral Approach

The Therapeutic Process in Voice Therapy Step I Identify the content of the person s negative thought process. The person is taught to articulate his or her self-attacks in the second person. The person is encouraged to say the attack as he or she hears it or experiences it. If the person is holding back feelings, he or she is encouraged to express them. Step II The person discusses insights and reactions to verbalizing the voice. The person attempts to understand the relationship between voice attacks and early life experience.

The Therapeutic Process in Voice Therapy Step III The person answers back to the voice attacks, which is often a cathartic experience. Afterwards, it is important for the person to make a rational statement about how he or she really is, how other people really are, what is true about his or her social world. Step IV The person develops insight about how the voice attacks are influencing his or her present-day behaviors. Step V The person then collaborates with the therapist to plan changes in these behaviors. The person is encouraged to not engage in self-destructive behavior dictated by his or her negative thoughts and to also increase the positive behaviors these negative thoughts discourage. If you are interested in attending a voice therapy training or in getting training materials please contact jina@glendon.org or visit www.glendon.org.

Steps in Voice Therapy

Self Anti-Self

Eight Ways to Actively Fight Depression Recognize and Conquer Your Critical Self Attacks Think About What You Could Be Angry At Be Active Don't Isolate Yourself Do Things You Once Liked to Do... even if you don't feel like it Watch a Funny TV Show or Movie Don't Punish Yourself for Feeling Bad See a Therapist Take Medication if Indicated

Guidelines for Continued Personal Development Be Aware of the Fear That Accompanies Change Realize That Psychological Pain is Valid Develop a More Realistic View of Your Parents Differentiation Unlearn Old Behaviors, Learn New Behaviors Become More Aware of Specific Defenses Against Feeling Recognize the Value of Friendship Seek Your Own Personal Meaning in Life

Differentiation 1. Differentiate from self-punishing voices. 2. Differentiate from undesirable traits in your parents that you see in yourself. 3. Differentiate from the defensive reactions you had (as a child self) and self-soothing voices. 4. Formulating and learning to live by your own values - who do you want to be?

Resources http://drdansiegel.com/resources/healthy_mind_platter/

Guidelines for Further Developing a Meaningful Life Practice Being Generous in All Your Relationships Become Aware of Existential Realities Develop a Spiritual Perspective and Appreciate the Mystery of Existence

A human being is a part of a whole, called by us 'universe', a part limited in time and space. He experiences himself, his thoughts and feelings as something separated from the rest... a kind of optical delusion of his consciousness. This delusion is a kind of prison for us, restricting us to our personal desires and to affection for a few persons nearest to us. Our task must be to free ourselves from this prison by widening our circle of compassion to embrace all living creatures and the whole of nature in its beauty. Nobody is able to achieve this completely, but the striving for such achievement is in itself a part of the liberation and a foundation for inner security." - Albert Einstein

Resources: Books Visit www.psychalive.org for resource links

Resources: Films and Websites PsychAlive www.psychalive.org PsychologyToday - Compassion Matters www.psychologytoday.com/blog/compassion-matters Huffington Post http://www.huffingtonpost.com/lisa-firestone Visit www.psychalive.org for resource links

Upcoming Webinars Tina Bryson, Ph.D. Whole Brain Child: Revolutionary Strategies to Nurture a Child s Developing Mind Lisa Firestone, Ph.D. The Fantasy Bond Understanding & Preventing Suicide Emotional Health of Children Sheldon Solomon, Ph.D. Self-Esteem The Role of Death in Life James Gilligan, M.D. Understanding & Treating Violence Visit www.psychalive.org for more information or to register for additional webinars. http://www.psychalive.org/2011/04/psychalive_webinars/

Contact: glendon@glendon.org 800-663-5281 THE GLENDON ASSOCIATION (For Professionals) www.glendon.org (For the Public) www.psychalive.org